Health inspection·October 25, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, review of the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, interview with resident and staff, it was determined that the facility failed to accurately complete and resident assessment related to a resident's cognition for one of 12 residents reviewed. (Resident R38) Residents Affected - Few Findings include: Review of the CMS's RAI Version 3.0 Manual revealed the intent of section C as follow: The items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions. Under Item Rationale Health-related Quality of Life o Most residents are able to attempt the Brief Interview for Mental Status (BIMS), a structured cognitive interview. o A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. - Without an attempted structured cognitive interview, a resident might be mislabeled based on their appearance or assumed diagnosis. - Structured interviews will efficiently provide insight into the resident's current condition that will enhance good care. Planning for Care o Structured cognitive interviews assist in identifying needed supports. o The structured cognitive interview is helpful for identifying possible delirium behaviors C0100: Should Brief Interview for Mental Status Be Conducted? Coding Instructions o Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395135 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennypack Rehab and Care Center 8015 Lawndale Avenue Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 an interpreter is needed but not available. Level of Harm - Minimal harm or potential for actual harm o Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter Residents Affected - Few is needed, one is available. Review of Resident R38's clinical record revealed that he was admitted to the facility on [DATE] with the diagnoses of Sensorineural Hearing Loss (a hearing loss caused by damage to the inner ear or the nerve from the ear to the brain), mild cognitive impairment, and malignant neoplasm of the retina (cancer of the inner part of the eye). Review of Resident R38's Minimum Data Set (MDS- assessment of resident's care needs) dated August 3, 2023, revealed that section B0200 Hearing was coded 3 absence of useful hearing, B0300 Hearing Aid no hearing aid, B0600. Speech Clarity was coded 0 (clear speech), B0700. Makes Self Understood was coded 1 (Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time), B0800. Ability To Understand Others was coded 1 Usually understands - misses some part/intent of message but comprehends most conversation. Review of Section C0100 (Should Brief Interview for Mental Status (C0200-C0500) be conducted?) with instructions to attempt to conduct interview with all residents was coded yes-should be interviewed, Section C0200 Repetition of Three Words, C0300 Temporal Orientation (orientation to year, month, and day). and C0400 (recall) were coded as not assessed, Section C0500 BIMS score (brief interview for mental status) did not have a score. Telephone interview with corporate MDS coordinator, Employee E 11 conducted on October 23, 2023, at 11:51 am confirmed that section C0200, C0300 and C0400 should have been completed. Interview with Resident R38 conducted on October 23, 2023, following the non meal revealed that resident was verbally responsive had clear speech and understood the surveyor. Further observation revealed that resident had difficulty hearing but was able to hear once volume of voice was adjusted and speaking slowly. Resident did not verbalize any concerns. Resident interview conducted by Director of Nursing (DON), Employee E2 and observed by surveyor conducted on October 24, 2023, at 12:54 pm revealed that resident had clear speech and was able to understand and communicate with the Director of Nursing. Further resident revealed that he did not want to read his braille book at the time but requested some other activity. Interview with DON, Employee E2 confirmed that she was able to communicate with Resident R38. Further, review of Resident R38's clinical record revealed that there was no documented evidence that resident's cognition fluctuates. Interview with Activity Director, Employee E8 at 12:06 pm conducted on October 25, 2023 revealed that Resident R38 has always been able to speak clearly and was able to make his needs known verbally and that he was able understand when spoken to as long as the speaker speaks loud enough and clearly. Further she revealed that Resident R38 was able to participate in activities and was able to interact with staff and other resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395135 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennypack Rehab and Care Center 8015 Lawndale Avenue Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5(f) Medical record Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395135 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennypack Rehab and Care Center 8015 Lawndale Avenue Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on review of personnel files, Pennsylvania State nurse aide registry information, review of facility policy and staff interview, it was determined that facility did not ensure current registry verification for one of five registries reviewed. (Employee E7) Findings include: According to facility's 'Hiring' policy, revised January 2008, 4. The following criteria will be considered in determining whether an applicant is qualified for a particular job position: Ability to perform the essential functions of the job (with or without reasonable accommodations); Skill, knowledge, training, efficiency, etc.; and Certifications and licenses. Review of Nurse aide, Employee E7's personnel file revealed no evidence of training prior to date of hire. Further review of 'Acknowledgement and Provisional Employment from Pennsylvania,' dated September 8, 2023, revealed I am a non-certified nursing assistant applying to begin a state approved Nurse Aide Training Class, a criminal history check and clearance must be received prior to enrollment in the program, signed by Employee E7 and facility's representative. Further review revealed, Employee E7 started orientation on September 18, 2023. According to Pennsylvania State nurse aide registry database, there is no information available related to certification for Employee E7. Per interview with Nursing Home Adminstrator, Employee E1, on October 25, 2023 at 2:00 p.m., Employee E7 has been terminated as well as previous human resources (HR) employee who hired Employee E7. Facility is in process of seeking to hire another human resources employee. Further interview revealed that previous HR employee used 'LinkedIn' resource to hire Employee E7. 28 Pa Code 201.18(e)(1)(3) Management 28 Pa Code 201.19(3) Personnel policies and procedures 28 Pa Code 211.12(c) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395135 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennypack Rehab and Care Center 8015 Lawndale Avenue Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and procedures and interview with staff, it was determined that the facility failed to maintain an effective infection control program related to the transportation, sorting, washing, and drying of soiled resident clothing's and the storage of clean linens and residents' clothing in the laundry room. Residents Affected - Some Findings include: Review of facility Policy on Infection prevention and control program revealed that under section Policy Statement, and infection prevention and control program is (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. User section Policy Interpretation and Implementation, #2. The program is based on accepted national infection prevention control risk assessment. #3. The infection prevention and control program is a facility wide effort involving all disciplines and individual's and is an integral part of the quality assurance and performance improvement program. #11. Prevention of infection. a. Important facets of infection prevention include: 2. instituting measures to avoid complications or dissemination, 3. educating staff and ensuring that they adhere to proper techniques and procedure. Review of facility document entitled Clean Linen Storage and Handling revealed the following: Sort, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items. Observation of the multi-purpose room conducted on October 22, 2023 at 11:43 a.m. revealed that facility clean linens, blankets, towels and gowns were stored in three closets without closet doors in the Multi-purpose room which was also used as an office space and staff locker room. Further observation revealed that the middle closet of the three closets had curtain but was drawn open. Further, closet next to the door had linens and blankets on the floor. One closet had linens on a pallet, but some linens were also touching the floor. Interview with the Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 conducted at the time of the observation confirmed that the closet next to the door had linens and blankets on the floor. Observation of the laundry room located in the basement conducted on October 25, 2023, at 10:48 a.m. revealed that the basement was only accessible from inside the facility through a door leading to a wooden staircase. Further observation revealed that there was only one door to the laundry area. The room measured approximately 18 x 15 feet in size. immediately to the right of the door (right wall) was a space with a vacuum cleaner and a signage Clean Area posted on the wall. Then there were three dryers (non-commercial). On top of the dryers were five plastic bags of clothing and a plastic laundry basket with plastic bags and a box of latex gloves. The wall facing the door were two washing machines (non-commercial) with a sink between the two washing machines. On the corner of the room, between the washing machines and the dryers, was a (Catty Corner) space were a big pile of clear plastic bags of clothing on the floor reaching to the same height as the washing machines. Continue observation of the laundrey area revealed that to the left of the room (left wall) was a desk with computer and printer and further down the left wall was a metal rack containing, housekeeping supplies and scrubbing pads (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395135 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennypack Rehab and Care Center 8015 Lawndale Avenue Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for floor stripping machines. Further, running the entire length of the left wall close to the ceiling were pipes. Further, hanging on one of the pipes to were mop heads covering the entire length of the pipe from one end of the left wall to the other. Further, in the middle of the room was a large pile of blankets, comforters, curtains, wash cloths and sweeper mop cloths some in plastic bags and some were not. Further observation revealed that from the side of the pile, boxes were visible where some of the curtains and comforters were placed on and on top of the boxes the bottom of the pile could not be seen due to the size of the pile. Interview with Housekeeping staff, Employee E6 confirmed that the pile of blankets, comforters, curtains, wash cloths and sweeper mop cloths were items that had already been washed. Further Employee E6 revealed that the pile of clothing in the corner between the washing machine and the dryer were all soiled resident clothing and the pile bags on top of the dryer were clean resident clothing. Further interview revealed that the mop heads hanging from the pipes had been washed and was hanged there to dry and to store. Further Employee E6 revealed that the pile of curtains, blankets, wash cloths, sweeper mop cloths were all washed. Interview with Maintenance Director, Employee E5 conducted at the time of the observation revealed that the mops head were used to mop the kitchen floor and other floors in the building. Interview with Housekeeping staff, Employee E4 conducted at the time of the interview, revealed that they have been using the pipes to dry the mop heads. The observation of the laundry room revealed that there was no clear designated area for soiled items, and clean items. Further, sequence in which the soiled clothing and other soiled items were transported, delivered, sorted, washed, dried, folded and stored, did not allow for the prevention of contamination of the clean clothing by the soiled items. Observation of soiled clothing collection conducted with Housekeeping staff, Employee E6 on October 25, 2023, at 9:47 am revealed that Employee E6 used a yellow cart to transport soiled clothing. Employee 6 collected soiled clothing in a plastic bag from residents' rooms, transported them using the yellow cart and carries the bags of soiled clothes down to the basement by hand for washing. Interview with Housekeeping staff, Employee E6 conducted at the time of the observation revealed that she used the yellow cart to transport all soiled resident clothing to the basement door and she carried the bags of soiled clothing to the basement. Further Housekeeping staff, Employee E6 also revealed that she used the same cart to transport clothing back to residents' rooms and that she the yellow cart is clean occasionally. Further Employee E6 also revealed that other people also uses the cart for other purposes. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395135 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennypack Rehab and Care Center 8015 Lawndale Avenue Philadelphia, PA 19111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of pest control documentation and resident and staff interview, it was determined that the facility did not ensure to maintain an effective pest control program for five out of 18 residents reviewed (Residents R21, R11, R26, R49 and R39) Residents Affected - Few Findings include: Review of facility's policy 'Pest Control,' revised on May 2008, this facility maintains an on-going program to ensure that the building is kept free of insects and rodents. Interview with (Residents R21, R11, R26, R49 and R39) during resident council meeting on Tuesday, October 24, 2023 at 11:00 a.m., revealed that gnats are seen in residents' rooms, as well as shower rooms and dining room. Residents complained of seeing thousand-legger bugs as well as flies and gnats in their rooms. Additional interview with residents revealed that exterminator mostly addresses common areas during visits and does not inspect all of residents' rooms. Resident R18 resides in room B2-W, R11 resides in room A-8D, R26 resides in room B-4D, R49 resides in room A-11W, and R39 resides in room A6-W. Reviewed 'Service Inspection Report' for July 2023, August 2023, and September 2023. Review of 'Service Inspection Report' invoice on July 20, 2023, Inspected rooms A1 and A7 for biting insects. No activity seen at time of service. Review of 'Service Inspection Report' from September 14, 2023, inspected and treated rims A3 and A7 for roach activity no activity observed during service. Technician mostly focused on common areas, such as hallways, nursing station, kitchen, vending machines and restrooms. Gnats were observed in the Nursing Home Administrator's office intermittently during duration of survey from October 22, 2023 through October 25, 2023. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395135 If continuation sheet Page 8 of 8